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Vaccine injection procedure for infants, children, and adolescents[1]

Vaccine injection procedure for infants, children, and adolescents[1]
Age Preferred position Preferred
injection site*		 Pain reduction strategies
<12 months Held by caregiver (skin-to-skin contact for infants <1 month of age) IM:
  • Anterolateral thigh (vastus lateralis)
Subcutaneous:
  • Fatty tissue over anterolateral thigh
Before injection:
  • Application of topical anesthetic agent
  • Feeding (at breast or with bottle) or nonnutritive sucking (eg, pacifier use)
  • Administration of rotavirus vaccine (for infants who require rotavirus vaccine)
  • Administration of sucrose or glucose (for infants who do not require rotavirus vaccine)  
During injection:
  • Feeding (at breast or with bottle) or nonnutritive sucking (eg, pacifier use)
  • If possible, administration of multiple injections simultaneously (by two clinicians) rather than one after the other
  • Administration of PCV13 after other injections
  • Administration of MMR vaccine (if needed for travel or outbreak) after other injections
After injection:
  • Feeding (at breast or with bottle) or nonnutritive sucking (eg, pacifier use)
  • Swaddling, holding/cuddling, side/stomach position, shushing, and/rocking
  • Administration of acetaminophen or ibuprofen for pain
12 months through 2 years Held by caregiver IM:
  • Anterolateral thigh (vastus lateralis)
Subcutaneous
  • Fatty tissue over upper outer area of tricepsΔ
Before injection:
  • Application of topical anesthetic agent
  • Feeding (at breast or with bottle) or nonnutritive sucking (for children who continue to breastfeed, bottle-feed, or use a pacifier)
  • For children <2 years: Administration of sucrose or glucose
During injection:
  • Feeding (at breast or bottle) or nonnutritive sucking (for children who continue to breastfeed, bottle-feed, or use a pacifier)
  • Distraction (eg, with a video or toy)
  • Administration of PCV13 and MMR vaccine after other injections
After injection:
  • Feeding (at breast or with bottle) or nonnutritive sucking (for children who continue to breastfeed, bottle-feed, or use a pacifier)
  • Stroking, rocking, or "blowing the pain away"
  • Administration of acetaminophen or ibuprofen for pain
≥3 years Children 3 through 11 years:
  • Seated (may be held by caregiver)
Children ≥12 years:
  • Seated or lying down
IM:
  • Deltoid
Subcutaneous:
  • Fatty tissue over upper outer area of tricepsΔ
Before injection:
  • Application of topical anesthetic agent
During injection:
  • Video, music, verbal, or virtual reality distraction for children <12 years
  • Breathing distraction (eg, blowing bubbles or a pinwheel, deep breathing) for children <12 years
  • If PCV13 or MMR vaccine are necessary, administer after other injections
After injection:
  • Administration of acetaminophen or ibuprofen for pain
IM: intramuscular; PCV13: 13-valent pneumococcal conjugate vaccine; MMR: measles, mumps, and rubella.
* If multiple injections are required at the same visit, separate limbs should be used if possible. If necessary, two or more injections can be given in the same limb; they should be separated by at least 2.5 cm (1 inch), if possible.
¶ Sucrose 2 mL of 24% or 50% strength solution administered one to two minutes before injection; glucose 2 mL of a 30% strength solution can be used if sucrose is not available.
Δ The fatty tissue over the upper outer area of the triceps is the preferred site for subcutaneous injections in children ≥12 months of age; the fatty tissue over the anterolateral thigh is an alternative.
Reference:
  1. Taddio A, McMurtry CM, Shah V, et al. Reducing pain during vaccine injections: Clinical practice guideline. CMAJ 2015; 187:975.
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